Failure to Document and Justify Resident Discharges
Penalty
Summary
The facility failed to ensure that residents were permitted to return following hospitalization and did not provide adequate documentation to support the need for discharge. In three cases, residents were either discharged or not allowed to return without proper documentation in their medical records to justify the discharge. One resident with severe cognitive impairment and multiple diagnoses was discharged for allegedly violating the rights of others, but the discharge notice was not supported by appropriate documentation. Another resident, cognitively intact and with no prior incidents of abuse or misappropriation, was discharged after being found in possession of another resident’s cell phone, with the discharge notice citing violation of others’ rights, again without supporting documentation. A third resident, moderately cognitively impaired and with a history of encephalopathy and dementia, exhibited agitated behavior and was sent to the emergency room for evaluation. After hospitalization, this resident was not allowed to return and was transferred to another facility, but there was no documentation in the medical record regarding the discharge or the resident’s subsequent placement. Staff interviews confirmed that discharge notices and documentation were lacking or incomplete, and the facility’s own policy required comprehensive discharge planning and documentation, which was not followed in these cases.